Comparison of Intracoronary Versus Intravneous Tirofiban in Acute STEMI Patients Undergoing Primary PCI

Q: What is the clinical evidence from this study?

Study design: RCT. Population: Acute ST-elevation myocardial infarction (STEMI) (n=180). Intervention: Intracoronary tirofiban vs. Intravenous tirofiban. Primary outcome: TIMI flow grade 3 after PPCI (p=0.022).

Xiuying Tang; Runjun Li

doi:10.21203/rs.3.rs-1081547/v1

December 14, 2021Open Access

Comparison of Intracoronary Versus Intravneous Tirofiban in Acute STEMI Patients Undergoing Primary PCI

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Key result

Intracoronary administration of tirofiban significantly improved TIMI flow grade 3 (96% vs 86%) and reduced major adverse cardiovascular events (26% vs 43%) compared to intravenous administration in STEMI patients undergoing primary PCI.

Why the study?

To investigate the effect of intracoronary compared with intravenous tirofiban in acute STEMI patients treated with primary PCI.

Does intracoronary tirofiban improve coronary perfusion and clinical outcomes compared to intravenous tirofiban in acute STEMI patients undergoing primary PCI?

Key Points

To assess whether intracoronary delivery of tirofiban is superior to standard intravenous administration in patients with acute ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.
Randomized trial of 180 acute STEMI patients undergoing primary PCI, assigned 1:1 to receive either intracoronary tirofiban (n=90) or intravenous tirofiban (n=90), followed by a 24-hour intravenous infusion.
Both groups received standard dual antiplatelet therapy and were evaluated for coronary flow, ST-segment resolution, inflammatory and injury biomarkers, 6-month cardiac function, and adverse events including bleeding.
Intracoronary tirofiban significantly improved TIMI flow grading (p = 0.022), TMP grade 3 perfusion (p = 0.014), and 2-hour ST-segment resolution (p = 0.029) relative to the intravenous group.
Patients treated with intracoronary tirofiban had a significantly lower incidence of major adverse cardiovascular events (p = 0.012) and lower 5-day levels of CRP (p = 0.040), ESR (p = 0.001), and troponin I (p = 0.041).
Cardiac functional parameters, including cardiac output and left ventricular ejection fraction, significantly improved in the intracoronary group at 6 months post-discharge, with no significant difference in bleeding rates.

Study Design

Type

RCT (n=180)

Blinding

Open-label

Randomization

Randomized

Structured PICO

Does intracoronary tirofiban improve coronary perfusion and clinical outcomes compared to intravenous tirofiban in acute STEMI patients undergoing primary PCI?

P

Population

180 adult patients with acute STEMI undergoing primary PCI with hyperthrombotic burden, followed for 6 months after discharge.

I

Intervention

Intracoronary (IC) bolus of tirofiban (10 µg/kg over 1-3 min) followed by intravenous infusion over 24 hours at 0.15 µg/kg per minute, added to standard therapy (aspirin, clopidogrel/ticagrelor, ACEI/ARB, beta-blockers, statins).

C

Comparator

Intravenous (IV) bolus of tirofiban (10 µg/kg over 1-3 min) followed by intravenous infusion over 24 hours at 0.15 µg/kg per minute, added to standard therapy.

O

Outcome

Indices of coronary artery and myocardial perfusion (TIMI flow grading, TMP grade 3, number of thrombus aspirations, resolution of Sum-STR two hours after operation) and blood indices (BNP, CK, CK-MB, ALT, AST, NT-pro-BNP, UA, glucose, HbA1c, urea, Cr, TNI).surrogate

Main Result

Absolute Event Rate: 96% vs 86%

p-value: p=0.022

Intracoronary administration of tirofiban during primary PCI for STEMI improves myocardial perfusion and reduces in-hospital MACE compared to intravenous administration, without increasing bleeding risk.

Limitations

Small sample size and likely genetically non-diverse
No economic benefit analysis conducted
Short follow-up duration (in-hospital and 6 months after discharge)
Open-label design may have introduced observer and patient bias
small sample size and likely genetically non-diverse
did not conduct an economic benefit analysis
follow-up duration was short and limited to in-hospital time and 6 months after discharge
not a double-blind trial, which may have introduced observer and patient bias

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Implication

Supports intracoronary tirofiban during STEMI PPCI; confirms superior perfusion and reduced in-hospital MACE versus intravenous route.

Abstract

Objective: This study aimed to investigate the effect of intracoronary tirofiban compared to intravenously administered tirofiban in acute ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI). Methods: This study included 180 patients who were admitted with the diagnosis of acute STEMI and undergoing primary PCI. Patients were randomized into an observation group (n = 90) and control group (n = 90). Both groups received typical treatments, such as aspirin and clopidogrel/ticagrelor. During the procedure, the observation and control groups were administered intracoronary (IC) or intravenous (IV) injections of tirofiban, respectively, followed by an intravenous infusion of tirofiban for 24 hours. Changes in thrombolysis in myocardial infarction (TIMI) flow grading, TIMI myocardial perfusion grade 3 (TMP grade 3), thrombus aspiration, brain natriuretic peptide (BNP) levels, creatine kinase peak and inflammatory factor levels, infarct size, resolution of the sum of ST‐segment elevation (Sum‐STR) two hours after the operation, and cardiac functional parameters were investigated before and/or after treatment and 6 months after discharge. The incidence of major adverse cardiovascular events (MACE) and adverse reactions (AEs) such as bleeding were compared between the two groups. Results: There were no statistically significant differences observed in the indices of BNP, creatine kinase peak, cardiac functional parameters, thrombus aspiration, or incidence of bleeding between the two groups before treatment. Following treatment, TIMI flow grading and TMP grade 3 were improved in the observation group that received intracoronary tirofiban compared to the control group (p = 0.022 and p = 0.014, respectively). Additionally, the Sum‐umi two hours after operation in the observation group was better than that in the control group (p = 0.029). The incidence of MACEs in patients given IC tirofiban administration was lower than that in those given IV tirofiban (p = 0.012). Furthermore, levels of glutamic oxaloacetictransaminase (AST), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and myocardial troponin I (TNI) in the observation group was significantly decreased compared to the control group after five days of treatment (p = 0.039, p = 0.040, p = 0.001, and p = 0.041, respectively). Functional heart parameters including CO and LVEF were significantly improved in the observation group 6 months after discharge. Conclusion: This study found that IC administration of tirofiban in patients with STEMI who underwent PPCI improved TIMI, TMP flow and cardiac function including CO and LVEF 6 months after discharge, and reduced CRP, ESR, and TNI. However, the incidence of bleeding between the two groups was comparable. These findings suggest that IC administration should be applied in certain acute STEMI patients.

Discussion

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Cite This Study

Tang et al. (2021) conducted an RCT in Acute ST-elevation myocardial infarction (STEMI) (n=180). Intracoronary tirofiban vs. Intravenous tirofiban was evaluated on TIMI flow grade 3 after PPCI (p=0.022). Intracoronary administration of tirofiban significantly improved TIMI flow grade 3 (96% vs 86%) and reduced major adverse cardiovascular events (26% vs 43%) compared to intravenous administration in STEMI patients undergoing primary PCI.

synapsesocial.com/papers/6a8574559df929a58fad9d48 https://doi.org/10.21203/rs.3.rs-1081547/v1

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Comparison of Intracoronary Versus Intravneous Tirofiban in Acute STEMI Patients Undergoing Primary PCI

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Comparison of Intracoronary Versus Intravneous Tirofiban in Acute STEMI Patients Undergoing Primary PCI

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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